Computerization of workflows, guidelines and care pathways: a review of implementation challenges for process-oriented health information systems

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways. A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes. One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed. We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings

Supporting physicians and patients through recommendation: Guidelines and beyond

Item does not contain fulltex

What BPM Technology Can Do for Healthcare Process Support

Healthcare organizations are facing the challenge of delivering personalized services to their patients in a cost-effective and efficient manner. This, in turn, requires advanced IT support for healthcare processes covering both organizational procedures and knowledge-intensive, dynamic treatment processes. Nowadays, required agility is often hindered by a lack of flexibility in hospital information systems. To overcome this inflexibility a new generation of information systems, denoted as process-aware information systems (PAISs), has emerged. In contrast to data- and function-centered information systems, a PAIS separates process logic from application code and thus provides an additional architectural layer. However, the introduction of process-aware hospital information systems must neither result in rigidity nor restrict staff members in their daily work. This keynote presentation reflects on recent developments from the business process management (BPM) domain, which enable process adaptation, process flexibility, and process evolution. These key features will be illustrated along existing BPM frameworks. Altogether, emerging BPM methods, concepts and technologies will contribute to further enhance IT support for healthcare processes

D-WISE: Diabetes Web-Centric Information and Support Environment: Conceptual Specification and Proposed Evaluation

AbstractObjectiveTo develop and evaluate Diabetes Web-Centric Information and Support Environment (D-WISE) that offers 1) a computerized decision-support system to assist physicians to A) use the Canadian Diabetes Association clinical practice guidelines (CDA CPGs) to recommend evidence-informed interventions; B) offer a computerized readiness assessment strategy to help physicians administer behaviour-change strategies to help patients adhere to disease self-management programs; and 2) a patient-specific diabetes self-management application, accessible through smart mobile devices, that offers behaviour-change interventions to engage patients in self-management.MethodsThe above-mentioned objectives were pursued through a knowledge management approach that involved 1) Translation of paper-based CDA CPGs and behaviour-change models as computerized decision-support tools that will assist physicians to offer evidence-informed and personalized diabetes management and behaviour-change strategies; 2) Engagement of patients in their diabetes care by generating a diabetes self-management program that takes into account their preferences, challenges and needs; 3) Empowering patients to self-manage their condition by providing them with personalized educational and motivational messages through a mobile self-management application. The theoretical foundation of our research is grounded in behaviour-change models and healthcare knowledge management.We used 1) knowledge modelling to computerize the paper-based CDA CPGs and behaviour-change models, in particular, the behaviour-change strategy elements of A) readiness-to-change assessments; B) motivation-enhancement interventions categorized along the lines of patients' being ready, ambivalent or not ready; and C) self-efficacy enhancement. The CDA CPGs and the behaviour-change models are modelled and computerized in terms of A) a diabetes management ontology that serves as the knowledge resource for all the services offered by D-WISE; B) decision support services that use logic-based reasoning algorithms to utilize the knowledge encoded within the diabetes management ontology to assist physicians by recommending patient-specific diabetes-management interventions and behaviour-change strategies; C) a mobile diabetes self-management application to engage and educate diabetes patients to self-manage their condition in a home-based setting while working in concert with their family physicians.ResultsWe have been successful in creating and conducting a usability assessment of the physician decision support tool. These results will be published once the patient self- management application has been evaluated.ConclusionsD-WISE will be evaluated through pilot studies measuring 1) the usability of the e-Health interventions; and 2) the impact of the interventions on patients' behaviour changes and diabetes control

Healthcare Process Support: Achievements, Challenges, Current Research

Healthcare organizations are facing the challenge of delivering high-quality services to their patients at affordable costs. To tackle this challenge, the Medical Informatics community targets at formalisms for developing decision-support systems (DSSs) based on clinical guidelines. At the same time, business process management (BPM) enables IT support for healthcare processes, e.g., based on workflow technology. By integrating aspects from these two fields, promising perspectives for achieving better healthcare process support arise. The perspectives and limitations of IT support for healthcare processes provided the focus of three Workshops on Process-oriented Information Systems (ProHealth). These were held in conjunction with the International Conference on Business Process Management in 2007-2009. The ProHealth workshops provided a forum wherein challenges, paradigms, and tools for optimized process support in healthcare were debated. Following the success of these workshops, this special issue on process support in healthcare provides extended papers by research groups who contributed multiple times to the ProHealth workshop series. These works address issues pertaining to healthcare process modeling, process-aware healthcare information system, workflow management in healthcare, IT support for guideline implementation and medical decision support, flexibility in healthcare processes, process interoperability in healthcare and healthcare standards, clinical semantics of healthcare processes, healthcare process patterns, best practices for designing healthcare processes, and healthcare process validation, verification, and evaluation

Leveraging workflow control patterns in the domain of clinical practice guidelines

Background: Clinical practice guidelines (CPGs) include recommendations describing appropriate care for the management of patients with a specific clinical condition. A number of representation languages have been developed to support executable CPGs, with associated authoring/editing tools. Even with tool assistance, authoring of CPG models is a labor-intensive task. We aim at facilitating the early stages of CPG modeling task. In this context, we propose to support the authoring of CPG models based on a set of suitable procedural patterns described in an implementation-independent notation that can be then semi-automatically transformed into one of the alternative executable CPG languages. Methods: We have started with the workflow control patterns which have been identified in the fields of workflow systems and business process management. We have analyzed the suitability of these patterns by means of a qualitative analysis of CPG texts. Following our analysis we have implemented a selection of workflow patterns in the Asbru and PROforma CPG languages. As implementation-independent notation for the description of patterns we have chosen BPMN 2.0. Finally, we have developed XSLT transformations to convert the BPMN 2.0 version of the patterns into the Asbru and PROforma languages. Results: We showed that although a significant number of workflow control patterns are suitable to describe CPG procedural knowledge, not all of them are applicable in the context of CPGs due to their focus on single-patient care. Moreover, CPGs may require additional patterns not included in the set of workflow control patterns. We also showed that nearly all the CPG-suitable patterns can be conveniently implemented in the Asbru and PROforma languages. Finally, we demonstrated that individual patterns can be semi-automatically transformed from a process specification in BPMN 2.0 to executable implementations in these languages. Conclusions: We propose a pattern and transformation-based approach for the development of CPG models. Such an approach can form the basis of a valid framework for the authoring of CPG models. The identification of adequate patterns and the implementation of transformations to convert patterns from a process specification into different executable implementations are the first necessary steps for our approach.This research has been supported by: 1) Austrian Science Fund (FWF) through project TRP71-N23. 2) Spanish Ministry of Education through grant PR2010-0279, and by Universitat Jaume I through project P11B2009-38

Flexible Support of Healthcare Processes

Traditionally, healthcare information systems have focused on the support of predictable and repetitive clinical processes. Even though the latter can be often prespecified in formal process models, process flexibility in terms of dynamic adaptability is indispensable to cope with exceptions and unforeseen situations. Flexibility is further required to accommodate the need for evolving healthcare processes and to properly support healthcare process variability. In addition, process-aware information systems are increasingly used to support less structured healthcare processes (i.e., patient treatment processes), which can be characterized as knowledge-intensive. Healthcare processes of this category are neither fully predictable nor repetitive and, therefore, they cannot be fully prespecified at design time. The partial unpredictability of these processes, in turn, demands a certain amount of looseness. This chapter deals with the characteristic flexibility needs of both prespecified and loosely specified healthcare processes. In addition, it presents fundamental flexibility features required to address these flexibility needs as well as to accommodate them in healthcare practice

Implementation of workflow engine technology to deliver basic clinical decision support functionality

BACKGROUND: Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. RESULTS: We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. CONCLUSIONS: We describe an implementation of a free workflow technology software suite (available at http://code.google.com/p/healthflow) and its application in the domain of clinical decision support. Our implementation seamlessly supports clinical logic testing on retrospective data and offers a user-friendly knowledge representation paradigm. With the presented software implementation, we demonstrate that workflow engine technology can provide a decision support platform which evaluates well against an established clinical decision support architecture evaluation framework. Due to cross-industry usage of workflow engine technology, we can expect significant future functionality enhancements that will further improve the technology's capacity to serve as a clinical decision support platform

Integration Architecture for Smart Campus Services and Solutions

Introducción: La Institución Universitaria Antonio José Camacho (UNIAJC) ha identificado a través del proyecto de investigación Ecosistema Smart campus, que existen problemas complejos de comunicación entre aplicaciones construidas como silos, donde la redundancia de información es común y los procesos que soportan requieren refinamiento. Esta problemática es bastante común, no solo para la UNIAJC, sino en general para cualquier universidad. La razón, es que a medida que evolucionan las instituciones, los aplicativos que soportan sus procesos son construidos únicamente visionando dar solución a una necesidad específica, sin contar con todo el contexto de soluciones que preexisten, muchas veces por la premura de resolver. Las arquitecturas orientadas a servicios (SOA por sus siglas en inglés), tienen como objetivo, resolver este tipo de situaciones de forma gradual, debido a la dificultad técnica de las implementaciones. Este trabajo se enfoca en exponer la definición de la arquitectura de integración que plantea Smart Campus para la UNIAJC, estableciendo la forma en que interactuarán los servicios y teniendo en cuenta las limitaciones de infraestructura actuales. Objetivo: Definir una arquitectura de integración que permita el fácil escalamiento y buen desempeño de los diversos mecanismos que  comunican las aplicaciones que cohabitan en la institución Universitaria Antonio José Camacho. Metodología: Se aborda el diseño arquitectural de la solución, partiendo del enfoque general, donde se describe las necesidades a resolver mediante el patrón Enterprise Service Bus (ESB) y se representan por medio de un diagrama de componentes. Luego se amplía la información hasta lograr un enfoque detallado. En este último, se selecciona el tipo de servicio a construir (SOAP o REST) y se expone su arquitectura. Por último, mediante ATAM (Architecture Tradeoff Analysis Method), se comprueba la efectividad de la solución. Resultados: La definición de una Arquitectura de integración de aplicaciones basado en SOA, detallando la arquitectura de software para la construcción de los servicios web de la solución. Esto, teniendo en cuenta las limitaciones de infraestructura y recursos de la Institución para lograr un rendimiento de entre 500 p/s a 1000 p/s (peticiones por segundo) que evite problemas de hilos o bloqueo de recursos.  Conclusiones: SOA permite dar solución a problemas de comunicación e integración de aplicaciones, tanto en entornos empresariales como educativos, incrementando la mantenibilidad, escalabilidad y reutilización de los sistemas y componentes desarrollados bajo esta arquitectura. Por otro lado, el modelo para la revisión de la arquitectura ATAM facilitó la definición y evaluación de la arquitectura, logrando tener una comprensión del entorno actual, la identificación de los atributos de calidad, las pruebas y resultados esperados.Introduction: The Antonio José Camacho University Institution (UNIAJC) has identified, through the Ecosystem Smart campus research project, there are complex communication problems between applications built as silos, where the redundancy of information is common and the processes they support require refinement. This problem is quite common, not only for UNIAJC, but in general for any university. The reason is that as institutions evolve, the applications that support their processes are built solely with the vision of providing a solution of a specific need, without counting on the entire context of pre-existing solutions, often due to the haste to resolve. Service-oriented architectures (SOA) aim to resolve these types of situations gradually, due to the technical difficulty of the implementations. This work focuses on exposing the definition of the integration architecture proposed by Smart Campus for UNIAJC, establishing the way in which the services will interact and taking into account the current infrastructure limitations. Objective: To define an integration architecture that allows easy scaling and good performance of the mechanisms that communicate the applications, which cohabit at the Antonio José Camacho University institution. Method: A brief description of the methodological design of the study.  The architectural design of the solution is approached, starting from the general approach, where the needs to be solved are described using the Enterprise Service Bus (ESB) pattern and are represented by a component diagram. The information is then expanded to a detailed focus. In the latter, the type of service to be built (SOAP or REST) is selected and its architecture is exposed. Finally, using ATAM (Architecture Tradeoff Analysis Method), the effectiveness of the solution. Results:  The definition of an SOA-based application integration architecture, detailing the software architecture for building the solution's web services. This, taking into account the Institution's infrastructure and resource limitations to achieve a performance between 500 p / s to 1000 p / s (requests per second) that avoids thread problems or resource blocking Conclusions: SOA enables solutions to communication and application integration problems, both in business and educational environments, increasing the maintainability, scalability and reuse of the systems and components developed under this architecture. On the other hand, the ATAM architecture review model facilitated the definition and evaluation of the architecture, achieving an understanding of the current environment, the identification of quality attributes, tests and expected results